This is essential, both for medicolegal reasons and for future reference. In practice, I tend to use a mixture of traditional and modern terminology to describe my treatment. If there is a traditional acupuncture point at the site I have used I note that; otherwise I use a description based on Western anatomical terminology. I also record the side (L or R), together with any other relevant information, such as the duration of needling (if unusual) and the effects, if any. Thus an initial treatment might be recorded as follows:
Lr 3 L,R (brief stim.): general reaction ++ (euphoria – ? strong reactor)
or:
TP in L gluteus medius: painful ++; sensation down to ankle.
Another way of recording one’s treatment is to mark it on a drawing.
On a subsequent attendance one should also record the outcome, possibly with a VAS.
The BMAS record sheet as supplied to candidates for the Certificate of Basic Competence provides a template for these details.
